Failure to Prevent Suspended CNA from Providing Care After Abuse Allegation
Penalty
Summary
The facility failed to develop and implement written policies and procedures that effectively prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not ensure that a certified nursing assistant (CNA) who had been suspended following an allegation of verbal abuse by a resident was restricted from providing care to that resident upon returning to work. Documentation revealed that the CNA continued to provide care to the resident after the suspension, contrary to the intended protective measures. The resident involved was an older female with multiple complex medical and psychiatric diagnoses, including Multiple Sclerosis, incomplete paraplegia, and severe bipolar disorder with psychotic features. She had significant memory impairment, exhibited both physical and verbal behaviors, and required extensive assistance with activities of daily living. The resident was unable to complete cognitive interviews and was noted to have difficulty recalling the incident in question during subsequent interviews. The facility's investigation into the alleged abuse was inconclusive, but the lack of clear and enforced policies allowed the suspended CNA to resume care duties for the resident. Interviews with staff confirmed that the CNA had continued to provide care, and that room assignments were made by the charge nurse without adequate safeguards to prevent the CNA from being assigned to the resident. The facility's existing policy on abuse and neglect did not provide sufficient guidance or enforcement to prevent this lapse.